Ruminations by a non-academic general surgeon from the heart of the rust belt.

Friday, September 25, 2009

Forgotten Man

I recently finished Amity Shlaes' book on the Great Depression, The Forgotten Man. It's a compelling, swift read; I encourage all to check it out. The term "forgotten man" was originally coined by this guy named William Sumner in the 19th century. His formulation was as follows---- Suppose you have entities A and B who are in positions of economic and political power. Both realize that entity C is unfairly compromised and excluded from sharing in their bounty. A sense of shame and justice and perhaps humanitarianism prompts A and B (the federal government and the capitalistic Masters of the Universe, respectively) to get together to try and find a way to help C (the poor and needy). But instead of directly assisting C, A and B instead identify X--- the forgotten man, the man who grinds through life, earns his own way, pays his taxes, doesn't ask or require anything of the government--- but because X lacks political standing, A and B find it is easy to place the burden of philanthropic redistribution on him. FDR of course had his own formulation of the forgotten man. In FDR's scheme, the forgotten man is just C and it is up to A and B to provide for his welfare.

Anyway you define it, I'm drawn to this concept of forgotten men in American life. As a surgeon, I cross paths with the downtrodden and forgotten rather frequently. We meet in the middle of the night, often, in lonesome, half-lit emergency rooms. Usually I find them sprawled uncomfortably on rickety stretchers, a thin hospital sheet stretched across their torso and limbs, never long enough, yellowed toes, bony pale hairless shins exposed. They never remember me the next day. They lay in the stretcher writhing in pain. They ask for more morphine. They can't remember how they ended up here. It's been going on for days. It hurts. Doc, it hurts and they turn towards the wall, clutching their abdomens. I review the films and the lab work and I try to explain what is happening, the perforated viscus, the appendicitis, whatever the hell it is, but I can tell they don't care. Just make it better they say. But when I turn to look for family, for a loved one, there's no one there. There's no one to call either. They've come into my life seemingly all alone....

I had a guy not too long ago who presented with a perforated duodenal ulcer. It was 3AM but I didn't mind driving in, already awake from my baby crying. It's nice sometimes to drive with the windows down on a cool summer night while the rest of the world slumbers. The smell of the dew dampened trees and grass and the sounds of the nighttime insects. The ER was empty. It must have been a Monday or Tuesday night. According to the EMS runsheet, the patient had been found down at the Shell gas station where he worked. He had peritonitis and looked deathly ill. He was 48 years old. His teeth were bad and he had that look of a chronic alcoholic, thin and disheveled and beaten down. We rushed him upstairs to the OR. After washing out a couple of liters of bile and gastric acid from his abdominal cavity, I patched the ulcerated hole in his duodenum with a tongue of well vascularized omentum. It was a quick, efficient case. We got him to the ICU within the hour. The family waiting area afterwards was dark and empty. There were no phone numbers of loved ones on his chart. I showered, lay down for an hour and then started my rounds.

A few days later I was surprised to see an older woman in his room while he slept. She introduced herself as his aunt. He had been living with her for the past several months. She asked about his condition. I informed her he was improving. She rolled her eyes. Probably fell off the wagon again, she said. Actually, no, I said. His blood alcohol level was zero when he arrived. Well, I'm sure this little adventure will give him an excuse to start hitting the bottle again, she said dismissively. I don't know how the hell he's going to make his rent this month. And then she walked off. I never saw her again.

As the days went by, my patient made remarkable progress. He turned out to be a very gentle and genuinely nice man. He seemed ever grateful for the care he'd received. He shook my hand on rounds. He always smiled, even when it was obvious he was hurting. The nurses loved him. He worked hard every day, walked the halls, used his incentive spirometer. I had had him on a prophylactic alcohol withdrawal protocol but that turned out to be unnecessary. He had been dry for 8 months now. He was working 50 hours a week at the gas station, saving his money. By day 6 he was eating and we were able to discharge him home.

Two weeks later, I saw him in the office. I hardly recognized him. He had showered and shaved and was wearing a button down shirt with corduroy pants. You could tell the clothes were brand new, the packaging creases still prominent. His wound had healed beautifully. He was back to work already. His boss had been very kind, granting him some time off. After a quick exam we talked for a bit. He opened up about his life. He was moving out of his aunt's spare bedroom into his own apartment. He didn't like his aunt so much. But she was the only family member who hadn't completely rejected him. Admittedly, he hadn't always lived his life the way he would have liked. He had made mistakes. He had been selfish. There was a lot in his history he wasn't proud of. But things were different now. There was hope etched into the lines of his coarse, aged face. He was hoping to get a night manager's position at the gas station later in the summer. Things were better. He had met a woman. He had a daughter in Phoenix he hadn't seen in years he was hoping to visit in the fall. And he was categorically grateful for the second chance he'd been given to make his life better. I can't express how thankful I am you took care of me, he said. You saved my life. It's hard to know what to say or how to act when someone says stuff like that to you. You were just doing your job. It wasn't personal. I'm just happy you got well again. It doesn't become personal until later, once the patient has conclusively recovered. And then you allow for a bit of unadulterated emotion to seep into the doctor-patient relationship, like two old war buddies talking about old times over a beer years later. Actually, that's not exactly true. As doctors we become attached to many of our patients almost from the beginning. But we hold back, restrain the heartstrings from thrumming for the sake of clinical objectivity and professionalism. There will be time for letting down your guard later, after you've successfully led the patient through the morass of illness. Eventually he had to leave. I haven't seen him since. I hope things are still well. I hope he's still dry and made amends with his estranged daughter. Hopefully he got that night manager's job. As time elapses, it gets harder and harder to remember what he looks like, the haziness of time blurring the edges of his face.

There was another forgotten soul from this summer I've wanted to write about. He was a veteran of the Vietnam War who had been battling alcohol abuse for years. He had been bouncing around Cleveland for the past decade, intermittently homeless, sometimes living with a loyal brother, sometimes crashing with fellow bums in ramshackle abodes. About five years ago he had tried to kill himself. His employment record was spotty. He was basically eking out an existence on the periphery of the American Dream. One night, after a massive binge, he took a pistol, pointed it down at his abdomen, and pulled the trigger. I was on trauma call that night when he rolled into the resuscitation bay. He was this emaciated, broken heap of a man bleeding out from his self inflicted wound. We intubated him, stabilized him as much as possible and rushed him to the OR. The bullet had entered his abdomen just below his ribcage on the right side, tore through the left lobe of his liver, blasted through the tail of his pancreas, exploded the top half of his left kidney, finally coming to a rest in a muscle belly of his back, inches from his spine. I opened his abdomen and encountered 3 or 4 liters of blood. We moved quickly. You pack all four quadrants, maintain your cool, and then systematically explore. The liver injuries were controlled with pressure and some whipstitches. Half of his pancreas was unsalvageable so I had to do a distal pancreatectomy. The kidney looked like a grenade had gone off in it and it was actively spurting blood so I performed a quick total nephrectomy. Foprtunately his bowels had been spared. There was no fecal or enteric contamination. I put some drains in and closed up shop. Initially his course was a little stormy. He went into alcohol withdrawal. He was intubated for over a week. But he slowly got better. He developed a persistent yellowish/brown drainage from one of his Jackson-Pratt drains and the evaluation of the fluid revealed this to be evidence of a pancreatic fistula (a not uncommon complication of pancreatic resections, especially when performed under duress). He went to a rehab facility with his drain and has been seeing me every few weeks in the outpatient clinic. He has VA eligibility but he doesn't want to see anyone else. Every few weeks we review the daily drain output volumes that he has meticulously written down on a wrinkled shard of paper, sometimes even the back of a napkin. The outputs remain too high. The fistula may not close spontaneously. So I've had to make arrangements for him to see a GI specialist in the VA system for an ERCP and to make sure he gets approved for the pancreatic secretion-reducing medication octreotide. It adds a lot of work to my ledger. I guess it would be easier to just dump him onto a surgeon at the VA for management. But I dont. He doesn't want that. See you in a few weeks Dr. Parks, he says.

We never formally talked about why he ended up like this. We never directly addressed his suicide attempt. He saw a psychiatrist and all that and he denies any persistent suicidal ideations currently but I still worry about him. He hasn't had a drink since the accident and he seems to be somewhat hopeful about the future. But he also knows the score. He's 58 years old. He hasn't done a whole lot with his life. Other than his brother, he doesn't have much of a social support structure. He never married. He has no children. He's been in and out of trouble with the law in multiple states. Since the accident, though, he's lived a very simple life. He doesn't drink or brawl or stumble around in chaos anymore. He wakes, eats a little, empties his drain and records how much comes out. He walks the streets where his brother lives. He used to bowl but he doesn't do that anymore. Before bed he empties the drain again and writes down what comes out. I half hope that damn fistula never closes.

I don't care what formula you want to use for who the forgotten man is. A, B, C, or X. In real life, there are no equations or secret formulations for the downtrodden and forgotten. They're all around us. We get so caught up in our silly, post modernist American lives we don't notice them, or we choose not to notice. Lonesomeness is pervasive. Those forlorn blank faces that pass you on the street, sitting silently across from you on the bus, the gaunt and weary who disappear into the background tapestry of life. We don't see them. We choose not to. We fear the light they shine into our own souls, the precariousness and utter abandonment of it all. We turn our heads, afraid to see our own reflection mirrored in the forgotten shadows of their lives....

I am not certified in anything remotely medical although it's what I aspire to since almost every job I've ever had was medical. And reading your blog, I can only hope to have the compassion you display. None of that, in my opinion is learned on the job. It is part of who you are as a person. I say that if I ever needed a surgeon, I might find you. At least I would know you remembered my name and what I was about. Even if these men never find your blog, someone out there knows them and you have left something good behind. The world is much smaller than we think it is. Thanks for a wonderful read.

great post buckeye. As a med-student who sometimes obsessively weighs the pros and cons of this specialty vs that, you remind me that it really doesnt matter in the end. Taking care of patients is why I went to med-school and as long as I get that satisfaction, the rest is details.

Enjoyed your warm posting. I'm a grey-headed RN, been at it over 30 years and did plenty of time in critical care. And recovered alcoholics are generally the nicest, most gracious and grateful people I've tended too. But we shouldn't be too hard on the family members that have abandoned them, or the aunt that rolls her eyes. In the throes of the drinking disease, these people did terrible damage, even unforgiveable damage, to their families.

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